COM October 2009

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October 2009: Gingival swelling left posterior mandible

Dolphine Oda, BDS, MSc
doda@u.washington.edu

Contributed by
Dr. Charles Weber
Oral & Maxillofacial Surgery, Olympia, WA

Case Summary and Diagnostic Information

This is a 65-year-old white female with a rapidly enlarging gingival swelling interproximal to teeth #s 19 & 20. This swelling was of three weeks’ duration and is red and ulcerated. The lesion was not painful and the patient’s only complaint was that the lesion was growing larger. It was 0.8 x 1.2 cm in greatest dimensions. Radiographs were negative for any bony changes. The patient denied tobacco use. She drinks 1-2 glasses of wine per week.

History of present Illness

This is a 65-year-old white female with a rapidly enlarging gingival swelling interproximal to teeth #s 19 & 20. This swelling was of three weeks’ duration and is red and ulcerated. The lesion was not painful and the patient’s only complaint was that the lesion was growing larger. It was 0.8 x 1.2 cm in greatest dimensions. Radiographs were negative for any bony changes. The patient denied tobacco use. She drinks 1-2 glasses of wine per week.

Figure 1 Photograph is taken at clinical presentation demonstrating an exophytic, red and ulcerated gingival mass on the buccal aspect between teeth #s 19 & 20.

Medical History

The patient’s past medical history is significant for osteoarthritis, hypertension and hypercholesterolemia.

Clinical and Radiographic Findings

The patient reported a rapidly growing gingival swelling between teeth # 19 & 20. It was red and ulcerated and was of three weeks’ duration. The mass was exophytic and friable. There was no palpable lymphadenopathy.

Excisional Biopsy

Treatment

Under local anesthesia, an excisional biopsy was performed. The excision was carried down to the periostium with 2mm clinical margins and interproximal tissue was removed down to bone. Upon notification of the histopathologic diagnosis, the patient was referred to an otolaryngologist. A CT scan of the mandible, neck and chest was negative except for an enlarged lymph node near the left submandibular gland. Definitive surgical treament was performed by the otolaryngologist and Dr. Weber. Under general endotracheal anesthesia, a left supraomohyoid neck dissection and left segmental mandibulectomy including removal of teeth # 19, 20, and 21 were performed. The inferior alveolar neurovascular bundle was spared. The defect was reconstructed with a split thickness skin graft. Dental implants are planned in the future.

Incisional Biopsy

Histologic examination of the H & E sections of the incisional biopsy showed surface epithelium exhibiting neoplastic changes and invading the underlying connective tissue. The epithelial changes were manifested in loss of maturation, alteration in the nuclear/cytoplasmic ratio, nuclear and cellular pleomorphism, increased mitotic activity, individual cell keratinization and keratin pearls. The invasion took the form of sheets, islands and nests of neoplastic epithelial cells. The connective tissue was also infiltrated by plasma cells, lymphocytes and neutrophils.

Figure 2 Low power (x40) the H & E histology reveals a piece of oral mucosa exhibiting an ulcerated/eroded neoplastic surface epithelial cells invading the underlying connective tissue.

Figure 3 Low power (x100) the H & E histology of a slightly higher power shows the neoplastic epithelial cells invading the connective tissue in form of sheets. The neoplastic epithelial cells show evidence of loss of maturation, frequent mitotic figures, large nuclei with prominent nucleoli, individual cell keratinization, keratin pearls and other type of atypical changes.

Figure 4 High power (x400) the H & E histology shows the neoplastic epithelial cells at a closer look.

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